Open Access Maced J Med Sci. 2019 Jul 30; 7(14):2343-2349. 2343
ID Design Press, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2019 Jul 30; 7(14):2343-2349.
Dental Science - Case Report
Orthodontic Treatment of a Periodontally - Affected Adult Patient
Stevica Ristoska1*, Biljana Dzipunova2, Emilija Stefanovska1, Vasilka Rendzova3, Vera Radojkova-Nikolovska1, Biljana
1Department of Oral Pathology and Periodontology, Faculty of Dental Medicine, Ss Cyril and Methodius University of Skopje,
Skopje, Republic of Macedonia; 2Department of Orthodontics, Faculty of Dental Medicine, Ss Cyril and Methodius University
of Skopje, Skopje, Republic of Macedonia; 3Department of Restorative Dentistry, Faculty of Dental Medicine, Ss Cyril and
Methodius University of Skopje, Skopje, Republic of Macedonia; 4Department of Oral and Maxillofacial Surgery, Faculty of
Dental Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
Citation: Ristoska S, Dzipunova B, Stefanovska E,
Rendzova V, Radojkova-Nikolovska V, Evrosimovska B.
Orthodontic Treatment of a Periodontally - Affected Adult
Patient (Case Report). Open Access Maced J Med Sci.
2019 Jul 30; 7(14):2343-2349.
Keywords: Adult orthodontics; Periodontal health;
Orthodontic appliances; Periodontal disease; Root
resorption; Orto-perio treatment
*Correspondence: Stevica Ristoska. Department of Oral
Pathology and Periodontology, Faculty of Dental
Medicine, Ss Cyril and Methodius University of Skopje,
Skopje, Republic of Macedonia. E-mail:
Received: 03-Jun-2019; Revised: 15-Jul-2019;
Accepted: 17-Jul-2019; Online first: 20-Jul-2019
Copyright: © 2019 Stevica Ristoska, Biljana Dzipunova,
Emilija Stefanovska, Vasilka Rendzova, Vera Radojkova-
Nikolovska, Biljana Evrosimovska. This is an open-access
article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International
License (CC BY-NC 4.0)
Funding: This research did not receive any financial
Competing Interests: The authors have declared that no
competing interests exist
BACKGROUND: The advanced periodontal disease is characterised by a strongly pronounced loss of attachment
and reduction of the alveolar bone support, which leads to luxation, migration of the teeth, functional discomfort
and poor facial aesthetics.
CASE PRESENTATION: The aim of this paper is to present the case of a 26-year-old female patient, registered
at the Clinic of Periodontology with highly expressed gingivitis, unsatisfactory periodontal status, presence of
diastemas between the frontal teeth and attachment loss of 5-6 millimetres in different areas. We conducted a
thorough classic periodontal treatment, as well as training for proper maintenance of oral hygiene, with frequent
professional oral-prophylactic sessions, complemented with orthodontic treatment. Fixed orthodontic appliances
were installed, and mild forces were applied for gradual levelling of the teeth, with constant control of the
periodontal status. After 20 months of treatment, the patient was in retention.
CONCLUSION: Orthodontic therapy of periodontally-affected teeth can begin only after exhaustive administration
of a periodontal treatment. Orthodontic treatment as an addition to the periodontal restoration must be gradual
with mild forces for an optimal dental response, thus helping to improve function, facial aesthetics and
psychological confidence of adult patients.
Dentofacial aesthetics is the primary
motivational factor in adolescent and adult population
for conducting orthodontic treatment. The number of
adult patients undergoing orthodontic therapy has
constantly been rising in the last 2-3 decades . 20-
25% of orthodontic patients are adults, and there is an
increasing trend in the number of adult patients as a
result of their increased awareness of the importance
of their oral health and their need for a better aesthetic
appearance . The main driving factor in adults is to
improve their dental and facial appearance , .
Twelve per cent of adults seeks orthodontic treatment
to prevent occurrence or progression of periodontal
Adult patients are divided into two different
groups: 1st group-young adults (under 35 years of
age, usually after their 20s) who were in need but
could not receive orthodontic treatment during the
adolescent period. The 2nd group consists of mature
patients in their 40s-50s who have other dental
problems and need orthodontic treatment as a part of
a larger therapeutic plan that includes numerous
dental disciplines .
Studies suggest that orthodontic therapy
providing good dental aesthetics also has a strong
impact on the psychosocial aspect of the patient's life
. It has been confirmed that almost 80% of patients
accept treatment because of the aesthetic aspect
Dental Science - Case Report
rather than dental health and function .
Today, orthodontic treatment can be
justified as a part of periodontal therapy if it is used to
reduce plaque accumulation, correct abnormal
gingival and osseous forms, improve aesthetics and
facilitate prosthetic replacement .
Age, per se, is not a contraindication to
orthodontic treatment. Fact is that the tissue’s
response to orthodontic forces, cell mobilisation and
conversion of collagen fibres is much slower in adults.
Adult bone is less reactive to orthodontic force. There
is a great risk of marginal bone loss and loss of
attachment with mild gingival infection . Dental
response to orthodontic forces is slower in adults, but
the teeth are moving in the same manner regardless
A large number of adult patients have
problems with malocclusion due to having neglected
their periodontal health, leading to a loss of bone
substrate around the teeth, resulting in pathological
migration, rotations, tipping and extrusions of the
teeth. Special attention should be given to the
periodontal status of adult patients since most of them
already suffer from periodontal disease. However,
orthodontic treatment is no longer a contraindication in
the therapy of advanced periodontal disease. This
treatment can help rescue and restore the
deteriorated dentition .
The advanced periodontal disease is
characterised by a strongly pronounced loss of
attachment, reduction of alveolar bone support,
leading to tooth mobility, pathological migration, tooth
extrusion, tipping, loss of contact point, presence of
spacing between the teeth and marginal gingival
recession. In many cases, this functional discomfort is
accompanied by a pronounced poor aesthetic in the
anterior dental region, which is reflected in the entire
The management of adult orthodontic
patients with severe bone loss continues to present a
challenge. Well-aligned dentition may be more
conducive to periodontal health, than a crowded
dentition and malocclusion. It has been widely
believed that appropriately applied orthodontic forces
do not damage the periodontium. On the contrary,
they can support the periodontal tightness, but oral
hygiene is obligatory.
Orthodontic therapy of the periodontally-
affected teeth can begin only after a thoroughly
performed periodontal treatment in multiple sessions
when the periodontal inflammation would be
eliminated. In a motivated patient who responds well
to initial periodontal therapy, orthodontic treatment
provides positive, satisfactory aesthetical and
functional results, and a good long-term prognosis.
Maintaining high-level oral hygiene at home, as well
as frequent professional visits is very important
(imperative) during and after the end of an active
orthodontic therapy . This can be supported by
findings of Mattingly , Paolantonio , Sallum
 and Perinetti , which confirm that long-term
fixed appliances can contribute to unwanted, but
predictable qualitative alterations in the subgingival
bacterial biofilm that become progressively pathogen
with time, if oral hygiene is not well. The combination
of orthodontic intrusion and periodontal treatment in
animals with good oral hygiene and healthy tissue
showed an improvement in the periodontal condition
. A reduction of probing depth in bone defects
following tooth extrusion can also be achieved .
General factors as morphology and deepness of
defects, oral hygiene, plaque control and patient
compliance, can strongly affect the predictability of
periodontal regeneration .
The goal of the paper is to show the
possibilities in the therapy of a periodontally-
compromised adult patient, patient selection,
preparations and stages of therapy, prerequisites for
success and further recommended surgical
A 26 years old female patient visited the Clinic
of Oral pathology and periodontology, complaining
about the wide spaces between her teeth, strongly
expressed gum bleeding and tooth luxation in the front
region. She complained of poor self-esteem and bad
social life. She was treated at our clinic for the first
time when she was 17. After a long period of time
without any therapy, she returned with those
There was no significant medical history of
any disease which may have contributed to
periodontal disease. However, she noted that one of
the parents had early teeth loss, and the two younger
sisters had a problem with bleeding from the gingiva.
Figure 1: Presence of diastema between upper left central and
Upon clinical examination, we noticed that
she had an asymmetrical face and a convex facial
Ristoska et al. Orthodontic Treatment of a Periodontally - Affected Adult Patient (Case Report)
Open Access Maced J Med Sci. 2019 Jul 30; 7(14):2343-2349. 2345
profile. The lips were incompetent, and she was
showing hyperactivity of the lower and upper lip while
closing the lips. There were also generalised deposits
of dental plaque and calculi due to poor oral hygiene.
No active caries lesions were present. The pocket
depth ranged from 3-6 mm in different areas of
dentition. Her periodontal condition was poor, with
gingival recession in many areas, especially in the
lower incisor region, presence of wide spaces
between the teeth, especially in the lower jaw as well
as in the upper left central and lateral incisor (Figure
1, Figure 2 and Figure 3).
Figure 2: Upper jaw from the occlusal side
Before starting with the therapy, the patient
was informed about the complications that could occur
during the orthodontic treatment such as the
possibility of root resorption, more bone loss around
the teeth and worsening of periodontal disease, as
well as the need to maintain oral hygiene at the
highest level. Informed consent was obtained from
Figure 3: Presence of wide spaces between the teeth in the lower
jaw and migration of the teeth
The periodontal treatment was started in
September 2015. We proceeded with a thorough
conservative periodontal treatment consisting of the
complete elimination of dental calculus and biofilm.
After that, scaling and root planning were conducted
in all 4 quadrants during several sessions. In the initial
phase of the therapy, due to the presence of a severe
expressed gingival inflammation, antibiotic therapy
was included as an addition to the conservative
treatment. In the whole duration of the process, the
patient was trained for proper maintenance of oral
hygiene at home.
This process was ongoing for over a year,
with frequent professional oral-prophylactic sessions
every 3-4 months. Over a year of observation before
the installation of orthodontic appliances helped us
judge the patient’s cooperation in oral hygiene
maintenance until it was made sure that it was
possible to start with orthodontic therapy. Ensuring
that the movement of the teeth would occur in a
healthy periodontal environment was of paramount
importance before proceeding with the therapy. If this
had not been done, orthodontically-applied forces
could enhance the gingival inflammation and destruct
the supporting tissues .
Figure 4: X-Ray before the start of the therapy
At the beginning of the periodontal treatment,
an X-Ray was made for precise detection of
periodontal status and osseous defects (Figure 4).
Figure 5: An upper fixed orthodontic appliance was placed
In January 2017, an upper fixed orthodontic
appliance was applied (Figure 5). 022 slot SWA was
used, alignment and levelling of the teeth were with
light forces using NiTi wires. To avoid the incisor root
desorption, we applied low intrusion forces (5-15
gr/tooth). In the second phase we used elastic bands
Dental Science - Case Report
with long filaments to close the spaces and make
Figure 6: Applied lower fixed orthodontic appliance
After six months, the lower fixed orthodontic
appliance was applied (Figure 6) and 022 slot SWA
was used, alignment and levelling were achieved with
light forces using NiTi wires and elastic bands with
Figure 7: Dental status at the end of the 1st year of orthodontic
At the end of first year of orthodontic therapy,
the oral situation was pleasant and as expected
(Figure 7 and Figure 8).
Figure 8: Improvement of the overall oral situation
After 20 months of active treatment, the
patient is in retention (Figure 9, 10, 11, and 12).
Figure 9: Dental status after 20 months of orthodontic therapy
Continuing monitoring of oral hygiene and
administration of Gengigel (0.8% hyaluronic acid) to
improve the attachment, was coordinated by the
Figure 10: Satisfactory results after 20 months
After an active orthodontic phase of 20
months, the spaces between her upper and lower
incisors were closed; the incisors were retracted to
achieve acceptable overjet and overbite relation.
Clinical examination revealed well-aligned arches, a
harmonious occlusion and good periodontal health.
Improved lip relationship, smile and facial esthetics
were achieved. Patient’s cooperation in oral hygiene
maintenance was satisfactory. The patient was very
satisfied with the treatment and had improved
Figure 11: Satisfactory facial appearance
Ristoska et al. Orthodontic Treatment of a Periodontally - Affected Adult Patient (Case Report)
Open Access Maced J Med Sci. 2019 Jul 30; 7(14):2343-2349. 2347
Orthodontic intrusion and levelling of
periodontally-migrated teeth changed the topography
of the original horizontal defects.
The therapeutic procedure at this patient will
continue with surgical treatment of the deep
periodontal defects in the frontal area and lateral
regions of the upper jaw, as well as overlapping the
recessions of the lower frontal teeth.
Figure 12: X-Ray at the end of the orthodontic treatment
The number of adult patients in need of
orthodontic treatment has increased in recent years.
The patient must be evaluated for systemic diseases,
perio-restorative problems, TMJ disorders and
vulnerability to root resorption. The biomechanics
must be customised for the individual treatment
requirement. It has been found that the expectations
of adult patients are usually high, and the limitations of
orthodontic treatment must be explained at the
beginning of treatment to arrive at realistic treatment
objectives . Thomson in his population-based
longitudinal study found that periodontal attachment
loss and gingival recession was not significantly
different between the orthodontic treatment group and
non-orthodontic treatment group . However, Hye-
Young Sim et al. investigated the association between
orthodontic treatment and periodontitis in a nationally
representative sample of the Korean population. The
results indicated that orthodontic treatment was
associated with decreased prevalence of periodontitis
. The importance of periodontal health has
increased as the number of adult orthodontic patients
Orthodontics can serve as an adjunct to
periodontal treatment procedures to improve oral
health in a number of situations. Achieving esthetically
acceptable results in periodontally-compromised
patients requires various teeth movements, which can
also help control the periodontal breakdown and
restore good oral function . The fixed appliance
allows easy splinting of teeth to achieve stable
anchorage , so force magnitude must be reduced
to minimum. According to Deppa , teeth alignment
can be achieved by orthodontic soft aligners in
periodontally involved teeth.
A viable periodontal ligament is important for
cell proliferation on the application of the orthodontic
forces. There is reduction in periodontal ligament
vascularity with ageing and insufficient source of
preosteoblasts. It is obligatory to use lighter,
controlled force levels in adults because the greater
forces result in vascular compression and necrosis of
blood vessels of periodontal ligament. There is a risk
of iatrogenic damage to the periodontium with
uncontrolled forces, and thus it is important to keep
the periodontal status under control during treatment.
Adults are more vulnerable to root resorption on
application of orthodontic force. Light continuous force
must be applied to minimise the risk of root resorption,
and the patient must be informed of the potential risks
before starting the treatment , , . Tulloch 
suggested that tooth movement can be undertaken 6
months after completion of active periodontal
treatment if there is sufficient evidence of complete
resolution of inflammation.
The most important factor in the initiation,
progression and recurrence of periodontal problems is
the presence of microbial plaque. Inadequate
maintenance of oral hygiene during orthodontic
treatment increases the risk of developing gingival
inflammation. There is much evidence of increased
count of Lactobacillus in saliva after orthodontic
braces placement . Many clinical studies have
reported that plaque accumulation and gingivitis
increased during orthodontic treatment . The
composition and types of oral bacteria were altered as
a result of orthodontic treatment , . Recent
animal studies suggested that orthodontic tooth
movement had a synergistic effect on the
periodontium by increasing the presence of Il-1 β and
The surgical phase consists of techniques
performed for pocket therapy and the correction of
related morphological problems, namely,
mucogingival defects. The purpose of surgical pocket
therapy is to eliminate the pathological changes in the
pocket walls, to create a stable, easily maintainable
state, and if possible, to promote periodontal
regeneration. A critical aspect of periodontal
regeneration is the stimulation of a series of events
and cascades, which can result in the coordination
and completion of integrated tissue formation .
Many approaches have been used involving
polypeptide growth and differentiation factors,
extracellular matrix proteins and proteins involved in
bone metabolism. These materials are largely
physiological molecules or molecules released by
cells which regulate processes in wound healing.
These growth factors, primarily secreted by
macrophages, endothelial cells, fibroblasts and
platelets, include platelet-derived growth factor
(PDGF), bone morphogenetic protein (BMP) and
transforming growth factor (TGF). These biological
mediators have been used to stimulate periodontal
Dental Science - Case Report
wound healing, promoting migration and proliferation
of fibroblasts (for periodontal ligament formation) or
promote the differentiation of cell to become
osteoblasts, thereby favouring bone formation .
Guided tissue regeneration (GTR), demineralised
freeze-dried bone allograft, or a combination of these,
are considered to be the most predictable
regenerative procedures for achieving favourable
treatment outcomes in periodontally-affected adult
patients. These findings were further supported by
many researchers who indicated that periodontal bone
grafts consistently led to better bone fill of the defect,
than the non-grafted controls. Histological analyses of
cementum regeneration in animals demonstrated that
regenerative treatment with bone grafting leads to
some degree of regenerated cement, periodontal
ligament and bone . Regenerative procedures
have a more predictable positive response in deep
and narrow defects rather than shallow ones.
A multidisciplinary approach is always
necessary to treat complex dental and periodontal
problems, and there cannot be a better example than
ortho-perio interaction. Periodontists should recognise
the importance of orthodontic intervention in achieving
results unattainable with periodontal therapy alone
, , . Adult orthodontic treatment can help
prevent or improve periodontal problems, can help
prevent and reduce further bone loss around teeth,
improve the dentist’s chances to restore missing
teeth, adjust aesthetics to get a better smile and facial
appearance, enhance function of teeth, increase self-
confidence and self-esteem, and finally, improve
overall oral health.
In conclusion, patient education, motivation,
enhanced oral hygiene maintenance and regular
periodontal care are essential during orthodontic
treatment. Orthodontic therapy in periodontally-
compromised patients requires extensive periodontal
care, before, during and after the treatment. In some
cases, periodontal restorative surgery may be
required for sealing the pockets. In order to prevent
relapse of the teeth to their previous state and ensure
long-term results, the appliance of lingual bonded
retainers is recommended. Interdisciplinary approach
complemented by patient education, cooperation and
good oral hygiene, will transform a patient with an
unattractive dentition due to periodontal breakdown
into a person with a good occlusion and a radiant
smile. Adult patients must undergo regular oral
hygiene procedures and periodontal maintenance to
maintain healthy gingival tissue during active
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